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Semi-continuous flow centrifugation systems – The shed blood is aspirated from the surgical field, mixed with anticoagulant, filtered, centrifuged and processed. “Cell-saving” Single or multiple-use, self-contained devices – The blood is collected and anticoagulated. The blood is then re-infused to the patient through a filter without being washed. “Simple autotransfusion” Intermediate/”mixed” systems

What is autotransfusion? What are the options?

• Intra-operative cell-saving

• Intra-operative simple autotransfusion

• Post-operative cell-saving

• Post-operative simple autotransfusion

Is autotransfusion beneficial?

Are blood-bank transfusions not OK?

How low does Hgb have to be before you decide to transfuse?

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Is autotransfusion beneficial?

Are blood-bank transfusions not OK?

How low does Hgb have to be before you decide to transfuse?

Does autotransfusion change results?

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[Pandas are so damn cute, and the parents knew they could just get another child]

Is autotransfusion beneficial?

Are blood-bank transfusions not OK?

How low does Hgb have to be before you decide to transfuse?

When is a transfusion necessary?

6.3 mmol/l 3.1 1.9 5.3 4.4

…..define ”necessary”!

Is autotransfusion beneficial?

Are blood-bank transfusions not OK?

How low does Hgb have to be before you decide to transfuse?

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Bad Santa?

• Expensive • Time consuming • Donor availability • Adverse reactions • Infection • Quality of blood

Flying (plane crash) 1:11 million Death Swimming (shark attack) 1:3.7 million Death Driving (car crash) 1:5000 Death Being a Danish soldier i Afghanistan 1:100 Death

Are transfusions safe?

Is bank blood as good as shed mediastinal blood?

• “This suggests that red cells saved from shed mediastinal blood have better oxygen transport capacity and may have longer survival compared to stored blood.”

Schmidt H et al.: Autotransfusion after open heart surgery: quality of shed mediastinal blood compared to banked blood. Acta Anaesthesiol Scand. 1995 Nov;39(8):1062-5.

”Waiter…there is too much blood in this soup!”

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

Before After Regist. changed

• Education on unwanted side-effects of blood-transfusion

• Tranexamic acid for all patients

• Lowered the acceptable Hgb. for selected patients

• Introduced ROTEM (thrombo-elastometry)

• Introduced a new transfusion protocol, where the indication had to be specified

• Focused on pausing platelet-inhibitors pre-op

• Introduced a local transfusion algoritm

What were the results of our ”blood saving” policy?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

Before After Regist. changed

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What were the results of our ”blood saving” policy?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

After Regist. changed

So…something happened…. ….but was it enough?

Our system for autotransfusion

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+

Unwashed blood (”simple autotransfusion”)

• Tissue debris • Activated platelets • Activated leucocytes • Thrombin and other pro-coagulants • Activated complement proteins • Fibrin degradation products • Red cell stroma • Micro-aggregates • Surgical debris • Anticoagulant solutions

What are the Potential Complications and Contraindications for Autotransfusion?

Potential complications: • Hemolysis • Air embolism • Dilution coagulopathy • Protein loss • Contaminants Potential contraindications: • Citrate-based anticoagulants in patients with impaired liver function • Gross contamination or septic procedures • Surgery within a malignant area • Biological contaminants • Contamination of blood with drugs not intended for intravenous administration • Collagen based hemostatic agents • Certain coagulopathies

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Maybe autotransfusion is bad?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

After Regist. changed

1st August 2007 we stopped using

autotransfusion

What were the results of our ”no autotransfusion” policy?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

After Regist. changed

So…the numbers for 2007 are a mix of

+/- autotransfusion

What were the results of our ”no autotransfusion” policy?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

Before After Regist. changed

How do we

improve data??

What were the results of our ”no autotransfusion” policy?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

Before After Registration changed

Baseline characteristics of CABG patients Should cell-saving be used?

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Why Wash Recovered Blood?

Washing serves the purpose of removing all other substances except the red blood cells from collected blood. The removed substances can include: • Plasma-free hemoglobin • Hemolyzed red blood cells • Pharmacologic agents • Bone fragments • Activated platelets • Irrigation solutions • Activated clotting factors

Is cell saving worth the money and the effort?

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITADrainage/OP

ITA SAG-M/OP

ITA FFPlasma/OP

ITA Platelets/OP

Before After Registration changed

2010 (literature up to 2009) 75 trials (31 cardiac surgery, 32 orthopedic surgery) Autotransfusion reduced RR of receiving allogenig RBC by 38% 0.68 units of RBC were saved pr. patient

• The results suggest cell salvage is efficacious in reducing the need for allogeneic red cell transfusion in adult elective cardiac and orthopaedic surgery. • The use of cell salvage did not appear to impact adversely on clinical outcomes. • However, the methodological quality of trials was poor. As the trials were unblinded and lacked adequate concealment of treatment allocation, transfusion practices may have been influenced by knowledge of the patients’ treatment status potentially biasing the results in favour of cell salvage.

What did they review? Methods of cell savage Of the 75 included trials, 48 studied cell salvage during the postoperative period, 16 studied intra-operative cell salvage, and 11 studied both intra-operative and post-operative cell salvage. One trial (Sait 1999) failed to describe the timing of cell salvage. Twenty-six trials studied cell salvage systems that reinfused washed salvaged blood, and 44 trials studied cell salvage systems that reinfused unwashed filtered salvaged blood. One trial (Rollo 1995) studied both washed and unwashed cell salvage (four-arm trial) and provided two comparisons of cell salvage (Rollo 1995a; Rollo 1995b). One trial (Klein 2008) studied intra-operative washed and post-operative unwashed cell salvage. For three trials (Mercer 2004; Sait 1999; Zhang 2008) the method used to process salvaged autologous blood prior to re-transfusion was unclear.

The post-operative transfusion trigger for haemoglobin (Hb) ranged from 7.0 g/dL to 10.0 g/dL, whereas the intra-operative Hb transfusion trigger value ranged from 5.6 to 10.0 g/dL.

Are there other options? When science fails……

….try religion….???